This series of rating 'ladders' is intended to allow a quantitative and qualitative analysis of the use of restrictive and intrusive interventions as part of the therapeutic management of violence and aggression in psychiatric hospital settings. This is an evolving handbook. The ladders are currently organised to facilitate a behavioural analysis. Context, antecedents, behaviour, interventions, consequences are conceptualised as a series of events organised in temporal sequence so that causes, interactions and effects can be considered. The complexity of analysis possible is limited by the statistical power of the numbers of cases and events available.

Background: The criteria for deciding who should be admitted first from a waiting list to a forensic secure hospital are not necessarily the same as for assessing need. Criteria were drafted qualitatively and tested in a prospective 'real life' observational study over a 6 month period. Methods: A researcher rated all those presented at the weekly referrals meeting using the DUNDRUM-1 triage security scale and the DUNDRUM-2 triage urgency scale. The key outcome measure was whether or not the individual was admitted. Results: Inter-rater reliability and internal consistency for the DUNDRUM-2 were acceptable. The DUNDRUM-1 triage security score and the DUNDRUM-2 triage urgency score correlated r = 0.663. At the time of admission, after a mean of 23.9 (SD35.9) days on the waiting list, those admitted had higher scores on the DUNDRUM-2 triage urgency scale than those not admitted, with no significant difference between locations (remand or sentenced prisoners, less secure hosp...

Developmental Understanding of Drug Misuse and Dependence DUNDRUM-D
This instrument has grown out of the series of prison psychiatric morbidity studies
carried out by the National Forensic Mental Health Service in the population of the Irish
Prison Service. The DUNDRUM-D is distinguished from other screening and diagnostic
instruments by the developmental perspective it takes on life time careers of substance
use, misuse and dependence. We recognise that those with substance misuse problems
commonly begin using intoxicants such as solvents very early, typically before the age of
12 and progress through other substances as they get older and are able to access more
expensive intoxicants. Some will have patterns of binge use, others are continuously
intoxicated. Some will use only one or two substances of choice; others will use many
different types of drug almost indiscriminately. It is not uncommon for a person to make
the transition from dependence on one drug to substitution for a...

This is the short version of the Developmental Understanding of Drug Misuse and Dependence DUNDRUM-D.
DUNDRUM-D is an instrument which has grown out of the series of prison psychiatric morbidity studies
carried out by the National Forensic Mental Health Service in the population of the Irish
Prison Service. The DUNDRUM-D is distinguished from other screening and diagnostic
instruments by the developmental perspective it takes on life time careers of substance
use, misuse and dependence. We recognise that those with substance misuse problems
commonly begin using intoxicants such as solvents very early, typically before the age of
12 and progress through other substances as they get older and are able to access more
expensive intoxicants. Some will have patterns of binge use, others are continuously
intoxicated. Some will use only one or two substances of choice; others will use many
different types of drug almost indiscriminately. It is not uncommon for a person to make
the transitio...

BACKGROUND:
Patients admitted to a secure forensic hospital are at risk of a long hospital stay. Forensic hospital beds are a scarce and expensive resource and ability to identify the factors predicting length of stay at time of admission would be beneficial. The DUNDRUM-1 triage security scale and DUNDRUM-2 triage urgency scale are designed to assess need for therapeutic security and urgency of that need while the HCR-20 predicts risk of violence. We hypothesized that items on the DUNDRUM-1 and DUNDRUM-2 scales, rated at the time of pre-admission assessment, would predict length of stay in a medium secure forensic hospital setting.
METHODS:
This is a prospective study. All admissions to a medium secure forensic hospital setting were collated over a 54 month period (n?=?279) and followed up for a total of 66 months. Each patient was rated using the DUNDRUM-1 triage security scale and DUNDRUM-2 triage urgency scale as part of a pre-admission assessment (n?=?279) and HCR-20 within 2...

BACKGROUND:
Decision making ability can change with time, depending on mental or physical health. Little is known about the factors that determine this change and the relationship of capacity to time. As a pilot for studies using functional mental capacities as an outcome measure, we sought to quantify this relationship measuring change over time using competence assessment tools, and rating scales for symptoms and global function.
METHODOLOGY:
We assessed 37 inpatients in a secure psychiatric hospital. All patients met the diagnostic and statistical manual of mental disorders-fourth edition and International classification of diseases, 10th edition criteria for an Axis 1 mental illness, all with psychosis. Patients were interviewed twice a mean of 323 days apart (median 176 days range 17-1221 days). The MacArthur competence assessment tools for consent to treatment (MacCAT-T) and fitness to plead (MacCAT-FP) were used to quantify functional capacity along with the Positive and Ne...

BACKGROUND:
A mental health needs assessment in the Irish prison population confirmed findings from other jurisdictions showing high prevalence of severe mental illness, including psychosis amongst those newly committed. We implemented a participatory action research approach in order to provide an integrated mental health prison in-reach and court liaison service for this population.
RESULTS:
Following extensive consultation, a two stage screening process was developed which was supplemented by an inter-agency referral management system. During the six years 2006-2011, all 20,084 new remands to the main remand prison serving 58% of the national population were screened. Following the first stage screen, 3,195 received a comprehensive psychiatric assessment. Of these 561 (2.8%) had symptoms of psychosis - corresponding to the prior research finding - and 572 were diverted from the criminal justice system to mental health services (89 to a secure forensic hospital, 164 to community...

This is the first systematic and representative survey of psychiatric morbidity in the Irish Prison population, using standardised research diagnostic methods. Five samples have been compiled, including 7% of all men committed to prison in 2003, 50% of all men in custody on remand, 15% of all sentenced men, 9% of all women committed to prison in 2003 and 90% of all women in prison. A total of 1,396 men and 186 women, 1,582 in all. Samples were closely representative of the total populations from which they were drawn. We also mapped the geographic origins of all those committed to prison over a twelve-month period.
We found that drugs and alcohol dependence and harmful use were by far the most common problems, present in between 61% and 79% of prisoners. Typically, prisoners were using multiple intoxicants, including alcohol, benzodiazepines, opiates, cannabis and stimulants. For all mental illnesses combined, rates ranged from 16% of male committals to 27% of sentenced men, whil...

Background
We set out to examine whether structured professional judgement instruments DUNDRUM-3 programme completion (D-3) and DUNDRUM-4 recovery (D-4) scales along with measures of risk, mental state and global function could distinguish between those forensic patients detained in a secure forensic hospital (not guilty by reason of insanity or unfit to stand trial) who were subsequently discharged by a mental health review board. We also examined the interaction between these measures and risk, need for therapeutic security and eventual conditional discharge.
Methods
A naturalistic observational cohort study was carried out for 56 patients newly eligible for conditional discharge. Patients were rated using the D-3, D-4 and other scales including HCR-20, S-RAMM, START, SAPROF, PANSS and GAF and then observed over a period of twenty three months during which they were considered for conditional discharge by an independent Mental Health Review Board.
Results
The D-3 distinguished ...

This ?Semi-structured Interview of Moral cognitionS? (SIMS) is a synthesis of our experience and research in
the fields of clinical/forensic psychology and forensic psychiatry. As an interview the SIMS aims to make the
non-understandable understandable and to demystify serious acts of violence. The ?Semi-structured Interview of Moral cognitionS? assesses six broad domains which may be associated
with violence (O?Reilly et al, 2017; Graham and Haidt, 2012). Five of the domains concern the moral themes
of ?Care-Harm,? ?Fairness-injustice?, ?Loyalty-Betrayal?, ?Authority?, and ?Purity?, which are drawn from moral
foundations theory (Haidt, 2007), in contrast the sixth domain focuses on ?Egoism and immorality?. The five
moral domains are thought to be innate and universal appearing in all cultures (Haidt, 2007). But cultures and
individuals may differ with regard to how specific acts are categorised allowing for considerable variation
(Haidt, 2007). Moral foundations theory and moral ps...

The Minister for Health, Dr. James Reilly T.D., established the National Advisory Committee on Bioethics in March 2012. The task of this Committee is to advise the Minister on the ethical and social implications of scientific developments in human medicine and healthcare.

Background
The START and SAPROF are newly developed fourth generation structured professional judgement instruments assessing strengths and protective factors. The DUNDRUM-3 and DUNDRUM-4 also measure positive factors, programme completion and recovery in forensic settings.
Methods
We compared these instruments with other validated risk instruments (HCR-20, S-RAMM), a measure of psychopathology (PANSS) and global function (GAF). We prospectively tested whether any of these instruments predict violence or self harm in a secure hospital setting (n?=?98) and whether they had true protective effects, interacting with and off-setting risk measures.
Results
SAPROF and START-strengths had strong inverse (negative) correlations with the HCR-20 and S-RAMM. SAPROF correlated strongly with GAF (r?=?0.745). In the prospective in-patient study, SAPROF predicted absence of violence, AUC?=?0.847 and absence of self-harm AUC?=?0.766. START-strengths predicted absence of violence AUC?=?0.776, but...

It has been estimated that one in four people will experience some form of mental ill-health
in their lifetime.1
This can range from feelings of anxiety, to depression, to more severe
mental health problems, such as psychosis. Most people can be treated in the community by
their GP or other mental health professional. However, some people will require more
intensive treatment, including admission to a psychiatric hospital. Many people will consent
to hospitalisation, while others may not wish to be admitted and may be detained
involuntarily. A third group of people may appear to be satisfied with their treatment plan
and although deemed âvoluntaryâ may, in reality, lack the decision-making capacity to
provide explicit consent.

Background: Moving a forensic mental health patient from one level of therapeutic security to a lower level or to the community is influenced by more than risk assessment and risk management. We set out to construct and validate structured professional judgement (SPJ) instruments for consistency and transparency in decision making Methods: Two instruments were developed, the seven-item DUNDRUM-3 programme completion instrument and the six item DUNDRUM-4 recovery instrument. These were assessed for all 95 forensic patients at Ireland's only forensic mental health hospital. Results: The two instruments had good internal consistency (Cronbach's alpha 0.911 and 0.887). Scores distinguished those allowed no leave or accompanied leave from those with unaccompanied leave (ANOVA F=38.1 and 50.3 respectively, p<0.001). Scores also distinguished those in acute / high security units from those in medium or in low secure / pre-discharge units. Each individual item distinguished the...

The DUNDRUM QUARTET:
This handbook describes a suite of four structured professional judgement instruments. These structured professional judgement instruments are intended to provide a validated and transparent means of making decisions about admission, transfer and discharge in forensic mental health / psychiatry services.
The DUNDRUM-1 triage security items are designed for the assessment of need for therapeutic security based on patient characteristics. Patients can be rated according to their need for high, medium, low or no therapeutic security.
The DUNDRUM-2 truage urgency items are intended to aid the prioritising of patients on a waiting list for admission to a therapeutically secure hospital.
The DUNDRUM-3 programme completion items describe the extent to which patients in a forensic secure hospital have engaged successfully in treatments under five `pillars? of care or domains relevant to reducing and managing risk of harm. These five domains are physical health, me...

BACKGROUND:
The assessment of those presenting to prison in-reach and court diversion services and those referred for admission to mental health services is a triage decision, allocating the patient to the appropriate level of therapeutic security. This is a critical clinical decision. We set out to improve on unstructured clinical judgement. We collated qualitative information and devised an 11 item structured professional judgment instrument for this purpose then tested for validity.
METHODS:
All those assessed following screening over a three month period at a busy remand committals prison (n = 246) were rated in a retrospective cohort design blind to outcome. Similarly, all those admitted to a mental health service from the same prison in-reach service over an overlapping two year period were rated blind to outcome (n = 100).
RESULTS:
The 11 item scale had good internal consistency (Cronbach's alpha = 0.95) and inter-rater reliability. The scale score did not correlate with...